Assisted ventilation immediately after birth with self-inflating bag versus T-piece resuscitator in preterm infants.

OBJECTIVE: To compare proportions of target range tidal volumes achieved with the self-inflating bag vs. the T-piece in resuscitation of preterm newborns at delivery. STUDY DESIGN: This randomized controlled trial was conducted at a tertiary Children's Hospital. 20 preterm infants≤32 weeks' gestational age with no congenital anomalies who needed positive pressure ventilation after birth were enrolled. Positive pressure ventilation was provided with the self-inflating bag or T-piece resuscitator. The primary outcome was proportion of inflations within a target range of 4-8 ml/kg. Chi-square and logistical regression analyses were performed. RESULTS: In the self-inflating bag (SIB) group 29% of inflations (117/419) and in the T-Piece (TP) group 51% of inflations (300/590) delivered expiratory tidal volume (TVe) of 4-8 ml/kg (p < 65.001). In the SIB group 60% of all inflations (254/419), and in the TP group 35% of all inflations (204/590) delivered TVe < 4 ml/kg (p < 0.001). In the SIB group 11% of all inflations (48/419), and in the TP group, 15% of all inflations (86/590) delivered TVe > 8 ml/kg (p = 0.18). The OR of having expiratory tidal volume of 4-8 ml/kg using the T-piece was 1.8 (CI 1.1-3.1), p = 0.02. CONCLUSION: Manual inflations provided by the TP deliver expiratory tidal volumes in the range of 4-8 ml/kg more consistently than SIB.

Impact of premedication on neonatal intubations by pediatric and neonatal trainees.

OBJECTIVE: To determine if premedication and training level affect the success rates of neonatal intubations. STUDY DESIGN: We retrospectively reviewed a hospital-approved neonatal intubation database from 2003 to 2010. Intubation success rate was defined as the number of successful intubations divided by the total number of attempts, and then compared by trainee's experience level and the use of premedication. Premedication regimen included anticholinergic, analgesic and muscle relaxant agents. RESULT: There were 169 trainees who completed 1071 successful intubations with 2694 attempts. The median success rate was 36% by all trainees, and improved with training level from 29% for pediatric trainees to 50% for neonatal trainees (P<0.001). Premedication was used in 58% of intubation attempts. The median success rate was double with premedication (43% versus 22%, P<0.001). CONCLUSION: Neonatal endotracheal intubation is a challenge for trainees. Intubation success rates progressively improve with experience. Premedication is associated with improved success rates for all training levels.

Changes in hemodynamics after rescue surfactant administration.

OBJECTIVE: To evaluate the hemodynamic changes occurring after rescue surfactant dosing in relation to the clinical respiratory response in preterm infants with respiratory distress syndrome. STUDY DESIGN: We studied 20 infants who received surfactant (poractant alfa) after failing continuous positive airway pressure (CPAP) beyond 2 h of life. Consecutive echocardiograms were performed before the surfactant dose, 10 min after and 1 h after the surfactant dose. Superior vena cava flow, right ventricular output, atrial and patent ductus arteriosus diameter and direction of shunting were measured. A surfactant responder (SR) was defined as an infant whose inspired fraction of oxygen was reduced to air (0.21) by 3 h after surfactant administration. A surfactant non-responder (SNR) was defined as an infant who remained on more than 0.21 at 3 h postsurfactant administration. Concurrent physiological parameters (heart rate, transcutaneous CO2, mean arterial blood pressure, mean airway pressure) were also recorded. Subject characteristics were compared relative to noted hemodynamic effects. RESULTS: Of the 20 infants enrolled in the study, 12 were SR. These infants received surfactant earlier and had increased measures of systemic blood flow after receipt of surfactant compared with baseline. SNR did not have changes in systemic blood flow from baseline after surfactant dosing. There was no change in ductal shunting or atrial shunting between the two groups. CONCLUSIONS: A good clinical response to rescue surfactant is seen in infants who received surfactant earlier and is associated with increase in systemic blood flow. Timing of rescue surfactant administration needs to be further evaluated in larger prospective studies.